Service Intensity Adjustment (SIA) Defines Better Hospice Care
The Medicare hospice benefit covers palliative and support services for beneficiaries who are terminally ill with a life expectancy of six months or less if the illness runs its normal course. When beneficiaries elect to enroll in the hospice benefit, they agree to forgo Medicare coverage for conventional treatment of their terminal illness and related conditions. According to the latest reported data from the National Hospice and Palliative Care Organization, 2018 NHPCO Facts and Figures published on 7/2/2019, in 2017 nearly 1.5 million Medicare beneficiaries (including more than half of decedents) received hospice services from 4,515 providers, and Medicare hospice expenditures totaled about $18.9 billion.
One feature of the hospice payment system implemented in 2016 is that it provides additional payment for certain visits in the last days of life. The purpose of these additional payments, referred to as service intensity adjustment (SIA) payments, is to pay hospices for the higher patient need and visit intensity in the last seven days of life.
Under the this payment system, the hospice provider is eligible for SIA payments for registered nurse and social worker visits that occur during the last seven days of life for patients receiving routine home care. The SIA payment is in addition to the base payment that the hospice receives for each day of care. SIA payments are calculated in 15-minute units up to a total of 16 units (or a total of 4 hours) per day as combination of both registered nurse and/or social worker visit time. This provides additional payments for care targeted toward those hospices that provide more visits in the last days of life.
All hospice providers are required to report all visits on their claims and must ensure the visit meets the definition as specified in section 30.3, page 43, of the Medicare Claims Processing Manual. “To constitute a visit, the discipline…must have provided care to the beneficiary. Services provided by a social worker to the beneficiary’s family also constitute a visit. For example, documentation in the medical/clinical record, interdisciplinary group meetings, obtaining physician orders, rounds in a facility or any other activity that is not related to the provision of items or services to a beneficiary, do not count towards a visit to be placed on the claim… In addition, the visit must be reasonable and necessary for the palliation and management of the terminal illness and related conditions as described in the patient’s plan of care.”
The 2019 published MEDPAC Chapter 12 data suggest that, in the first two years of the new payment system, the additional SIA payments have led to little change in the amount of time spent at bedside visiting patients at the end of life. As the data has shown little shift in visit utilization, Muse Healthcare saw a need to identify patients entering the last days of life and created a tool to help hospice agencies optimize their resources to ensure the best quality care for patients.
Developed by industry experts, Muse Healthcare is an advanced analytics platform driven by deep learning-based neural networks that accurately identify patients in need of additional focused care in the last 7 to 12 days of life. By using the millions of RN visit based physical assessments, interventions and goals, medications, vital signs, orders, and care communication notes; the Muse machine learning technology takes the entire context of the patient into consideration by uncovering the relationships between structured and unstructured data as they change over time. This process allows the hospice care team to quickly react to patients, coordinate care, schedule daily visits for all disciplines, enhance the “end of life” care plans, and ensure the patient and families are getting the care they deserve. While these additional visits will increase total cost of care to the hospice, the increase in the SIA payment will more than offset this increase. The intention of the SIA program created by Medicare is to follow the need of the patient and spend more hours with the patients when they are actively dying. By using the Muse tool, it will enable the SIA program as it was intended and will ensure the hospice provider is providing the best possible care.
The Muse platform is also proven to increase the number of referrals to the agencies. Referral Sources (both physician and facilities) want to refer patients to hospice agencies that provide more care at the right time in the hospice care cycle.